Behavioral Health Outpatient Treatment State policy

[Pages:21]Behavioral Health Outpatient Treatment

Provider Type 14 Billing Guide

State policy

The Medicaid Services Manual (MSM) is on the Division of Health Care Financing and Policy (DHCFP) website at (select "Manuals" from the "Resources" webpage).

? MSM Chapter 400 covers policy for behavioral health providers. ? MSM Chapter 100 contains important information applicable to all provider types.

Rates

Reimbursement rates are listed online at on the Rates Unit webpage. Rates are also available on the Provider Web Portal at medicaid. through the Search Fee Schedule function, which can be accessed on the Provider Login (EVS) webpage under Resources (you do not need to log in).

Smoking Cessation Counseling for Pregnant Women

As of October 13, 2011, CPT codes 99406 and 99407 are used to bill smoking cessation counseling for pregnant women only. For all other recipients, these services are billed using the appropriate Evaluation and Management (E&M) office visit code.

Authorization Requirements

Authorization is required for most behavioral health services, including those referred through the Early Periodic Screening, Diagnostic and Treatment (EPSDT) program. Use the Authorization Criteria search function in the Provider Web Portal at to verify which services require authorization. Authorization Criteria can be accessed on the Provider Login (EVS) webpage under Resources (you do not need to log in).

For questions regarding authorization, call Nevada Medicaid at (800) 525-2395 or refer to MSM Chapter 400. Prior authorization may be requested through the Provider Web Portal, , by using the appropriate FA form listed below:

? Form FA-10A: Psychological testing ? Form FA-10B: Neuropsychological testing ? Form FA-10D: Automated Testing ? Form FA-11: Behavioral Health Outpatient or Rehabilitative Authorization Request ? Form FA-11B: Mental Health Request for PHP/IOP Services (Partial Hospitalization Program and Intensive

Outpatient Program)

Incomplete requests may receive either a technical denial or may be pended for additional information, determined by what elements are missing. If the request is pended for additional information, the submitter has five business days to resubmit with complete information or a technical denial will be issued.

Please note that form FA-11 requires the signature of the Qualified Mental Health Professional (QMHP). If the QMHP is an intern, the signature of the Clinical Supervisor is also required. Requests will be denied if the required signatures are not included.

Authorization does not guarantee payment of a claim. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of benefits and other terms and conditions set forth by the benefit program.

Request timelines

? Initial request for Outpatient Mental Health (OMH) and Rehabilitative Mental Health (RMH) services: Submit no more than 15 business days before and no more than 15 calendar days after the start date of service, unless otherwise specified for a service in the Billing Guide or in the Billing Manual.

? Continued service requests: If the recipient requires additional services or dates of service (DOS) beyond the last

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Behavioral Health Outpatient Treatment

Provider Type 14 Billing Guide

authorized date, you may request review for continued service(s) prior to the last authorized date. The request must be received by Nevada Medicaid by the last authorized date of service and it is recommended these be submitted 5 to 15 business days prior to the last authorized date. ? Unscheduled revisions: Submit whenever a significant change in the recipient's condition warrants a change to previously authorized services. Must be submitted during an existing authorization period and prior to revised units/services being rendered. The number of requested units should be appropriate for the remaining time in the existing authorization period. ? Retrospective request (for recipient retroactive eligibility): Submit no later than 90 calendar days from the recipient's Date of Decision (i.e., the date the recipient was determined eligible for Medicaid benefits). All authorization requirements apply to requests that are submitted retrospectively. ? Emergency request for Crisis Intervention only: Submit within five (5) business days of the delivery of additional services, including the first date of service of the first occurrence.

Claim instructions

Use Direct Data Entry (DDE) or the 837P electronic transaction to submit claims to Nevada Medicaid. See Electronic Verification System (EVS) Chapter 3 Claims and the EDI companion guides for billing instructions.

Billing Instructions for Span Dating of Outpatient Mental Health (OMH) and Rehabilitative Mental Health (RMH) Services

For OMH and RMH services, non-consecutive dates and services that are not the same unit/time amount must not be span dated on a single claim line. Providers risk claim denials due to duplicate logic, overlapping dates and/or mutually exclusive edits.

When span dating, services must have been provided on every day within that span of dates and be for the same quantity of units on each day. In the following examples, it would be incorrect to submit a single span-dated claim line for the following services:

? The entire week or month when services were only performed on Thursday and Saturday within the same week; or

? The entire month was billed and services were only rendered on January 1 and January 10 (two days within the same month; see the example below); or

? If one hour, four units, were performed on January 1 and two hours, eight units were performed on January 2.

The claim should only contain dates of service the service was rendered on. If services were rendered January 1, January 5 and January 10, the claim would be submitted as follows with one line charge for each date of service:

01/01/15 01/05/15 01/10/15

When billing weekly or monthly, a single claim line cannot include dates from two calendar months. For example:

? A claim line with dates of service April 15-May 15 is not allowed, but a claim line with May 1-May 31 is acceptable, if services were provided on every day in the date span and the above criteria are met regarding same quantity of units provided on each day.

? A claim line with dates of service March 28-April 3 is not allowed, but one claim line with March 28-March 31 and a second claim line with April 1-April 3 is acceptable, if services were provided on every day in the date span and the above criteria are met regarding same quantity of units provided on each day.

Services billed must match services authorized. For example, if code H0038 with modifier HQ was authorized, this same code/modifier combination must be entered on the claim.

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Provider Type 14 Billing Guide

Intensity of Needs Grid

The Intensity of Needs grid is an approved Level of Care (LOC) utilization system, which bases the intensity of services on the assessed needs of a recipient. The determination level on the grid guides the interdisciplinary team in planning treatment to improve or retain a recipient's level of functioning or prevent relapse. Each Medicaid recipient must have an Intensity of Needs determination completed prior to approval to transition to more intensive services (except in the case of a physician or psychologist practicing as an independent provider). The Intensity of Needs grid is found in Medicaid Services Manual Chapter 400, Section 403.5 Outpatient Mental Health (OMH) Services ? Utilization Management. The service limitations for RMH services are found under the individual RMH service descriptions.

NOTE: Assessment, as listed in the Intensity of Needs grid, refers to H0031 (Mental Health Assessment by non-physician) and 90791 (Psychiatric Diagnostic Evaluation), also referred to as a full assessment. These limits do not apply to H0002 (Behavioral Health Screening to determine eligibility for admission to treatment program), also referred to as a Mental Health Screen. When H0031 or 90791 are performed, H0002 may not be billed separately.

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Provider Type 14 Billing Guide

Covered services

The following table lists covered codes, code descriptions and billing information as needed. The requirements for coverage and limitations are governed by MSM Chapter 400. If you need further clarification, please contact the Medicaid QIO-like vendor.

Qualified Provider Types as noted in the following table:

LCPC: Licensed Clinical Professional Counselor LCSW: Licensed Clinical Social Worker LMFT: Licensed Marriage and Family Therapist QBA: Qualified Behavioral Aide QMHA: Qualified Mental Health Associate QMHP: Qualified Mental Health Professional

Billing Code

Brief Description

Service Limitations

Qualified Provider Type(s)

Additional Instruction / Restriction

Prior Authorization Requirement

Intensity of Need

Screening and Assessment

96127

Brief emotional/behavioral

Assessment = 1 unit; QMHP, NOTE: This is considered a screening tool.

No

assessment (e.g., Depression

limit 2 units per day

LCSW,

Bill one unit for each screening.

Inventory, ADHD) with scoring and documentation per standardized

instrument.

LMFT, LCPC, QMHA

NOTE: A screening may also be a component of a full assessment, but only the full assessment (including a CASII or

LOCUS) will be reimbursable.

All Levels

H0002

Behavioral Health Screening to determine eligibility for admission to

treatment program

1 time every 90 days.

This screening must be conducted faceto-face before the

recipient can be

QMHP, LCSW, LMFT, LCPC, QMHA

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Bill one unit for each screening. Recipients must be re-screened every 90 days to

reevaluate their Intensity of Needs, which includes a CASII or LOCUS.

NOTE: A screening may also be a

No

All Levels

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Provider Type 14 Billing Guide

Billing Code

H0031

Brief Description

Service Limitations

determined eligible for Medicaid

behavioral health services

Qualified Provider Type(s)

Additional Instruction / Restriction

component of a full assessment, but only the full assessment (including a CASII or

LOCUS) will be reimbursable.

Prior Authorization Requirement

Intensity of Need

Mental Health Assessment by non-

Covered up to 4

QMHP,

Use this code for services provided in a

No

physician

times per calendar

LCSW,

home or community setting, not in an

year (CASII) or 2 LMFT, LCPC office setting. Psychotherapy services,

times per calendar

including for crisis, may not be reported on

year (LOCUS) based

the same day. E/M codes may not be

on Intensity of Needs

reported on the same day performed by

grid

the same individual for the same patient.

All Levels

90791

Psychiatric Diagnostic Evaluation

Covered up to 4 times per calendar

year (CASII) or 2 times per calendar year (LOCUS) based on Intensity of Needs

grid

QMHP, LCSW, LMFT, LCPC

Integrated biopsychosocial assessment, including history, mental status and recommendations. Psychotherapy

services, including for crisis, may not be reported on the same day. E/M codes may

not be reported on the same day performed by the same individual for the

same patient.

Yes. If there is substantial change in condition, subsequent assessments may be requested

through a PA.

All Levels

Diagnostic

96138 Psychological or Neuropsychological First 30 minutes

QMHP,

Psychological or neuropsychological test

Yes

All Levels

Test administration and scoring by

LCSW,

administration and scoring by technician,

technician

LMFT, LCPC

two or more tests, any method.

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Provider Type 14 Billing Guide

Billing Code

96139

Brief Description

Psychological or Neuropsychological Test administration and scoring by

technician

Service Limitations

Each additional 30 minutes

Qualified Provider Type(s)

QMHP, LCSW, LMFT, LCPC

Additional Instruction / Restriction

Psychological or neuropsychological test administration and scoring by technician,

two or more tests, any method.

Prior Authorization Requirement

Intensity of Need

Yes

All Levels

96146 96156

96158

Psychological and Neuropsychological test, automated Health and Behavior Assessment or

reassessment

Health and Behavior Intervention

N/A

Initial assessment, face-to-face with

patient

Individual, face-toface, Initial 30 minutes

QMHP,

Psychological or neuropsychological test

Yes

LCSW,

administration, with single automated,

LMFT, LCPC standardized instrument via electronic

platform, with automated result only.

QMHP, LCSW, LMFT, LCPC

Health behavior assessment, or reassessment (i.e., health-focused clinical interview, observations, clinical decisionmaking). Qualifying recipients present with primary physical illnesses, diagnoses or

symptoms and may benefit from interventions that focus on biopsychosocial

factors related to the recipient's health status.

4 units allowed per calendar year, PA to exceed

QMHP,

Includes promotion of functional

No

LCSW,

improvement, minimizing psychological

LMFT, LCPC and/or psychosocial barriers to recovery,

and management of and improved coping

with medical conditions. These services

emphasize active patient/family

engagement and involvement. Do not

report for less than 16 minutes of service.

All Levels All Levels

All Levels

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Billing Code

Brief Description

96159

Health and Behavior Intervention

96164

Health and Behavior Intervention, group (2 or more patients)

96165

Health and Behavior Intervention, group (2 or more patients)

96167

Health and Behavior Intervention, family (with patient present)

96168

Health and Behavior Intervention,

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Service Limitations

Qualified Provider Type(s)

Additional Instruction / Restriction

Prior Authorization Requirement

Intensity of Need

Each additional 15

QMHP,

Includes promotion of functional

No

minutes

LCSW,

improvement, minimizing psychological

LMFT, LCPC and/or psychosocial barriers to recovery,

and management of and improved coping

with medical conditions. These services

emphasize active patient/family

engagement and involvement.

All Levels

Initial 30 minutes,

QMHP, Qualifying recipients present with primary

No

face-to-face

LCSW,

physical illnesses, diagnoses or symptoms

LMFT, LCPC and may benefit from interventions that

focus on biopsychosocial factors related to

the recipient's health status. Do not report

for less than 16 minutes of service.

All Levels

Each additional 15

QMHP, Qualifying recipients present with primary

No

minutes, face to face

LCSW,

physical illnesses, diagnoses or symptoms

LMFT, LCPC and may benefit from interventions that

focus on biopsychosocial factors related to

the recipient's health status.

All Levels

Initial 30 minutes,

QMHP, Qualifying recipients present with primary

No

face-to-face

LCSW,

physical illnesses, diagnoses or symptoms

LMFT, LCPC and may benefit from interventions that

focus on biopsychosocial factors related to

the recipient's health status. Do not report

for less than 16 minutes of service.

All Levels

Each additional 15

QMHP, LCSW,

Qualifying recipients present with primary physical illnesses, diagnoses or symptoms

No

All Levels

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Billing Code

Brief Description family (with patient present)

Service Limitations minutes, face-to-face

Qualified Provider Type(s)

LMFT, LCPC

Additional Instruction / Restriction

and may benefit from interventions that focus on biopsychosocial factors related to

the recipient's health status.

Prior Authorization Requirement

Intensity of Need

96170

Health and Behavior Intervention,

Initial 30 minutes,

QMHP, Qualifying recipients present with primary

No

family (without the patient present)

face-to-face

LCSW,

physical illnesses, diagnoses or symptoms

LMFT, LCPC and may benefit from interventions that

focus on biopsychosocial factors related to

the recipient's health status. Do not report

for less than 16 minutes of service.

All Levels

96171

Health and Behavior Intervention, Each additional 15

QMHP, Qualifying recipients present with primary

No

family (without the patient present) minutes, face-to-face LCSW,

physical illnesses, diagnoses or symptoms

LMFT, LCPC and may benefit from interventions that

focus on biopsychosocial factors related to

the recipient's health status.

All Levels

Psychotherapy: For services beyond the Intensity of Needs grid to be considered for reimbursement, an approved PA must be listed on the claim. Service provision is based on the calendar year, beginning January 1. In accordance with the Current Procedural Terminology (CPT) manual, do not report psychotherapy of less than 16 minutes duration and follow the "Time Rule" when selecting the appropriate code.

90785

Interactive Complexity

Use only as an add-

QMHP,

Refers to specific communication factors

No

on with an

LCSW, that complicate the delivery of a psychiatric

appropriate CPT code LMFT, LCPC

procedure.

All Levels

90832

Psychotherapy

30 minutes; bill one unit per day

QMHP, LCSW, LMFT, LCPC

The patient must be present for all or most of the session.

Yes, based on the Intensity of

Needs grid.

All Levels

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